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Tumors of the stomach and duodenum

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1 Tumors of the stomach and duodenum

Benign Polyps Hyperplastic Fundic gland Neoplastic Multiple Tumors Leiomyomas Lipomas Heterotopic pancreas Malignant Tumors Carcinoma Lymphoma Sarcoma Carcinoid Others Menetriers Disease Bezoar Volvulus

3 GASTRIC POLYPS Hyperplastic polyps
Most common type of polyp (65 – 90%) Inflammatory or regenerative polyps In reaction to chronic inflammation or regenerative hyperplasia Often found in HP infections Sessile and seldom pedunculated Mostly in the antrum Multiple in 50% of cases Varying in size but seldom < 2cm Rate of malignant transformation 1 – 3% Usually larger than 2 cm

4 GASTRIC POLYPS Fundic Gland Small elisions in the fundus
Hyperplasia of the normal fundic glands Often associated with FAP Therefore important as a marker for disease elsewhere in the GIT tract

5 GASTRIC POLYPS Neoplastic polyps Types Macroscopically Treatment
Tubular Villous (often larger - > 2cm - and malignant) Macroscopically More often in antrum Pedunculated with malignant potential Solitary, large and ulcerated Treatment Endoscopic removal if no malignancy identified with surveillance Excision with malignant focus or where endoscopic removal failed

6 GASTRIC POLYPS Multiple gastric polyps Rare condition Treatment
Adenomatous and hyperplastic polyps 20% incidence f adenocarcinoma Treatment If confined to corpus and antrum – distal gastrectomy Otherwise total gastrectomy Sometimes associated with Polyposis syndromes FAP Gardner Peutz-Jeghers Cowden Cronkhite Canada

7 GASTRIC LEIOMYOMA Incidence of 16% at autopsy Pathology
Arise from smooth muscle of the GIT tract Difficult to distinguish from GIST 75% benign Differentiation only on mitotic index Large protruding elisions with central ulcer Usually presents with bleeding if at all Treatment is local excision with 2 – 3cm margin

8 GASTRIC LIPOMA Rare subcutaneous lesions Pillow sign Asymptomatic
On routine endoscopy Require no treatment Pillow sign

9 HETEROTOPIC PANCREAS Ectopic pancreas Rarely larger than 4 cm
Most common found in stomach Within 6 cm from the pylorus Also in Meckl’s diverticulum Rarely larger than 4 cm Sessile and rubbery Submucosal in location Histological identical to normal pancreas

Declining incidence in western world HP associated due to chronic atrophic gastritis Also related to Low dietary intake vegetables and fruit High dietary intake of starches More common in males ( 3 : 1 ) Histology Invariably adeno-carcinoma Squamous cell carcinoma from oesophagus Involves fundus and cardia

Histological typing Ulcerated carcinoma (25%) Deep penetrated ulcer with shallow edges Usually through all layers of the stomach Polipoid carcinoma (25%) Intraluminal tumors, large in size Late metastasis Superficial spreading carcinomas (15%) Confinement to mucosa and sub-mucosa Metastasis 30% at time of diagnosis Better prognosis stage for stage

Histological typing Linitis plastica (10%) Varity of SS but involves all layers of the stomach Early spread with poor prognosis Advanced carcinoma (35%) Partly within and outside the stomach Represents advanced stage of most of the fore mentioned carcinomas

Symptoms and signs Vague discomfort difficult to distinguish from dyspepsia Anorexia Meat aversion Pronounced weight loss At late stage Epigastric mass Haematemesis usually coffee ground seldom severe Metastasis Vircho node in neck Blumer shelf in rectum

Surgical resection only cure Late presentation makes sugary often futile Palliation controversial for Haemorrhage Gastric outlet Simple gastrectomy as effective as abdominal block Splenectomy often added due to direct involvement Only for the very distal partial gestrectomy Rest total gastrectomy Prognosis overall 12% 5 year survival 90% for stage I disease


16 GASTRIC LYMPHOMA 5% of all primary gastric neoplasm's
2 different types of lymphoma Part of systemic lymphoma with gastric involvement (32%) Part of primary involvement of the GIT (MALT Tumors) 10 – 20% of all lymphomas occur in the abdomen 50% of those are gastric in nature Risk factors HP due to chronic stimulation of the MALT In early stages of disease Rx of HP leads to regression of the disease

Early stages also referred to as pseudo-lymphoma Indolent for long periods Low incidence of Spread to lymph nodes Involvement of bone marrow Therefore much better prognosis Mostly involves the antrum 5 different types according to appearance Infiltrative Ulcerative Nodular Polypoid Combination

At time of presentation Larger than 10 cm (50%) More than 1 focus (25%) Ulcerated (30 – 50%) Pattern of metastasis similar to gastric carcinoma Signs and symptoms Occur late and are vague Relieved by anti-secretory drugs Diagnosis based on histology

Treatment controversial Surgical treatment for patients without systemic involvement Mandatory for high grade lesions Possible not needed for low grade lesions Total gastrectomy and en-block for direct involvement Sparing duodenum and oesophagus Palliative resection with intra-abdominal spread Good for bleeding, obstruction and perforations Radiation and chemotherapy combination for most

20 GASTRIC SARCOMA 1 – 3 % of gastric malignancies
Include a wide variety of tumors Leiomyosarcoma Leiomyoblastoma GIST

21 MENETRIERS DISEASE Giant gastric folds (hypertrophic gastropathy)
Differentiate from Infiltrating neoplasm (Ca / lymphoma) CMV infection Manifestation Hypo-proteinaemia due to loss from ruggae Chronic blood loss Treatment Medical (PPI, atropine, H2 blockers) Surgical for refractory cases or where Ca cant be excluded

22 GASTRIC BEZOAR Concretions in the stomach
Tricho-bezoar (hair) Young girls who pick and swallow their hair Phyto-bezoar (vegetable fibre) Can cause erosions and bleeding Seldom perforate but if mortality 20% Post-gastrectomy predisposes Both mechanical and chemical Endoscopic breakage

23 GASTRIC VOLUVLUS 2 Types Clinical triade (Brochardt’s) Organo-axial
Through the organs longitudinal axis More common and associated with hiatus hernia Eventration of the diaphragm Mesenterio-axial Line through mid lesser to mid greater curvature Clinical triade (Brochardt’s) Vomiting followed by retching and inability to vomit Epigastric distension Inability to pass NGT

24 GASTRIC VOLVULUS Treatment Emergency surgery as any volvulus

25 GASTRIC DIVERTICULAE True diverticulae uncommon
Involve all layers of the wall Pre-pyloric in location Pulsion with only mucosa and sub-mucosa Within a few cm of GEJ Asymptomatic found on routine investigations Confused with peptic ulceration

Benign Brunners gland adenoma Leiomyoma Carcinoid Heterotopic gastric mucosa Villous adenoma Malignant Peri-ampullar adeno CA Duodenum Cholangio Pancreatic head Leiomyosarcomas Lymphomas Others Duodenal dIverticula

27 DUODENUM Benign tumors
Brunners gland adenomas Small submucosal Sessile and pedunculated variants Posterior wall junction D1 and D2 Symptoms due to bleeding or onstruction Leiomyoma Asymptomatic Carcinoid Mostly active (gastrin, SS and serotonin) Simple excision

28 DUODENUM Benign tumors
Hetrotopic gastric mucosa Multiple small mucosal lesions No clinical significance Villous adenoma Intestinal bleeding Obstruction of ampulla with jaundice Risk of malignancy high (50%) Endoscopic snaring or local excision

29 DUODENUM Malignant tumors
Located in the descending part of the duodenum Symptoms Pain, obstruction bleeding and jaundice Earlier than pancreas head Treatment Pancreatico-duodenectomy for localized lesions Much better prognosis than pancreas Ca (30% 5-year as opposed to 0%) Palliative bypass procedures if not resectable Radiotherapy for advanced disease ?

Incidence 20% at autopsy 5 – 10% at upper GIT investigations Pulsion diverticulae 90% on the medial border of the duodenum Solitary and within 2.5 cm of the ampulla Associated gallstones and gallbladder disease Pseudo-diverticluae First part of the duodenum Scarring of PUD

Presentation Chronic post-prandial pain and dyspepsia With complicated disease Bleeding and perforation Panceatitis Jaundice Surgery for complicated disease Dissection, removal and closure (even with perforation) With billiary involvement : cholidocho-duodenostomy

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